Savoy Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mamou, Louisiana.
- Location
- 906 Cherry Street, Mamou, Louisiana 70554
- CMS Provider Number
- 195619
- Inspections on file
- 24
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Savoy Care Center during CMS and state inspections, most recent first.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
A resident with severe cognitive impairment and multiple neurologic and vascular diagnoses was observed on multiple occasions lying on an air mattress that was too small for the bedframe, resulting in the resident’s feet and head extending beyond the mattress and a gap of about one foot between the mattress and the bedframe. A CNA, the ADON, and the DON each confirmed that the mattress did not properly fit the bedframe and did not accommodate the resident’s height.
The facility did not ensure a fall mat was in place as ordered for a resident with severe cognitive impairment and failed to implement an increased water flush order for another resident receiving PEG tube feeding, as confirmed by staff observations and interviews.
A resident with multiple chronic conditions did not have the Medical Director timely notified of the Registered Dietician's recommendations for changes in tube feeding and protein supplementation. Although the recommendations were faxed, there was no follow-up call as required, and no response was received until after the resident's death in the hospital.
A facility failed to protect residents from abuse and neglect, resulting in Immediate Jeopardy. A CNA verbally abused a resident, causing emotional distress. Additionally, a resident with aggressive behavior physically abused two other residents, and the facility neglected a resident by not following the required two-person assist protocol during transfers. These incidents were not properly addressed or reported, indicating systemic issues in ensuring resident safety.
A facility failed to report multiple abuse incidents involving both staff and residents. A CNA verbally abused a resident, and a resident with severe cognitive impairment physically assaulted two other residents. Despite documentation and awareness of these incidents, the facility did not report them to the State Agency, leading to an Immediate Jeopardy situation.
The facility failed to investigate allegations of abuse involving three residents. A resident reported verbal abuse by a CNA, but the facility did not consider it an abuse allegation and failed to investigate. Another resident was hit by a fellow resident, but the DON did not investigate the physical aspect of the altercation. Additionally, a resident with severe cognitive impairment had her hair pulled by another resident, but the incident was not investigated as abuse. These failures resulted in an Immediate Jeopardy situation.
The facility did not provide water to 10 residents during lunchtime in Hall X dining room, offering only juice and milk with their meals. Observations and interviews confirmed that water was not included on meal trays and was only provided upon specific request.
The facility failed to effectively manage resources, leading to multiple instances of abuse and neglect. A resident was verbally abused by a CNA, while two residents experienced physical abuse from another resident. Additionally, a resident was neglected during a transfer. The facility lacked an effective system for reporting and investigating these incidents, resulting in a failure to recognize and address abuse and neglect.
A facility failed to ensure consistent documentation of a resident's advance directive. The resident, with multiple medical conditions, was listed as Full Code in the electronic record, while the physician's orders and care plan indicated a DNR status. Staff interviews confirmed reliance on the electronic record for code status, and the inconsistency was acknowledged by the DON.
A facility failed to complete a PASARR Level II screening for a resident who was diagnosed with Bipolar Disorder after admission. Initially admitted with a Level I screening indicating no mental illness, the resident's new diagnosis required a Level II screening, which was not conducted, as confirmed by the DON.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident with a history of falls was repeatedly observed without a required fall mat, while another had a fall mat improperly placed. Additionally, a resident requiring two-person assistance for bed mobility experienced a fall when care was provided by one CNA alone. These failures were confirmed by facility staff.
A facility failed to provide proper pressure ulcer care for a resident with a Stage 3 ulcer. The treatment nurse contaminated gloves by placing them on an unclean bedside table and did not follow proper infection control procedures, such as removing soiled gloves and sanitizing hands before continuing wound care. This compromised the resident's treatment and increased the risk of infection.
A facility failed to administer a resident's enteral flush according to physician orders. The resident, with multiple medical conditions including dysphagia, had an order for Glucerna 1.5 cal at 60cc/hour with 35cc/hour water flushes. Observations showed the water flush was set at 30cc/hour instead of the prescribed 35cc/hour, confirmed by the ADON.
A resident with severe cognitive impairment and shortness of breath was not provided with oxygen therapy as ordered by the physician. The resident's oxygen was set at 3 liters per minute instead of the prescribed 2 liters per minute. Facility staff, including an LPN and the DON, confirmed the discrepancy and acknowledged the need for adherence to physician orders for oxygen administration.
An LPN failed to maintain accurate documentation of controlled substances, resulting in discrepancies between the narcotic log and medication blister packs for two residents. The LPN admitted to not signing out the medications on the narcotic record log sheet after administration, and the DON confirmed that all controlled medications should be signed off immediately after administration.
A resident with cognitive impairment and dependency on staff for daily activities was found without a call bell within reach on multiple occasions, despite being able to use it to request assistance. Facility staff confirmed the call bell's inaccessibility and the resident's ability to use it, highlighting a deficiency in accommodating the resident's needs.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
Incompatible Mattress and Bedframe for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident’s mattress was compatible with and properly fit the bedframe, as required by the expectation that all bed frames, mattresses, and bed rails be regularly inspected for safety and that mattresses attach safely to the bed frame. The affected resident had an admission date of 12/07/2023 and diagnoses including Myoneural Disorder, Paraplegia, Epilepsy, and Peripheral Vascular Disease, with a Quarterly MDS BIMS score of 6 indicating severe cognitive impairment. On 03/23/2026 at 11:39 a.m., surveyors observed the resident lying in bed with his feet hanging off the mattress, which appeared too small for the bedframe. On 03/24/2026 at 10:12 a.m., further observation showed the resident lying on his back with his head elevated on an air mattress that did not fit the bedframe properly, leaving approximately a 1-foot gap between the top of the bedframe and the head of the mattress, with the resident’s head partially above the mattress. At 12:48 p.m., a CNA confirmed the mattress did not fit the bedframe and explained that pulling the resident and mattress up in the bed would create a gap at the footboard. At 1:00 p.m., the ADON confirmed the mattress was not accommodating to the resident’s height and should be. At 3:00 p.m., the DON observed that the air mattress was approximately 1 foot smaller than the bedframe and confirmed that the bed was not accommodating the resident and that the mattress did not fit the bedframe properly.
Failure to Follow Physician Orders for Fall Prevention and Tube Feeding Care
Penalty
Summary
The facility failed to provide services in accordance with professional standards of practice for two residents. For one resident with severe cognitive impairment and total dependence on staff for self-care and transfers, a physician's order and care plan intervention required a fall mat to be in place at the bedside following a recent fall. However, during observation, the fall mat was not present, and facility staff confirmed it should have been in place as ordered. For another resident who was dependent on staff for all activities of daily living and received nutrition and hydration via PEG tube, the registered dietician recommended, and a physician's order was entered, to increase the water flush from 30ml/hr to 40ml/hr. Despite this, observations on multiple occasions showed the water flush remained set at 30ml/hr. Staff interviews confirmed the order had not been implemented as required, and nursing staff had not verified or adjusted the pump settings to ensure the resident received the prescribed water flush.
Failure to Timely Notify Medical Director of Dietician Recommendations
Penalty
Summary
The facility failed to ensure that services were provided in accordance with professional standards of practice by not notifying a resident's Medical Director of the Registered Dietician's recommendations in a timely manner. According to the facility's policy, dietician notes and recommendations are to be given to the Director of Nursing (DON) for nursing staff to send to the physician for review and follow-up. In this case, a resident with multiple complex diagnoses, including supraventricular tachycardia, chronic kidney disease, chronic obstructive pulmonary disease, cardiac pacemaker, aphasia following cerebrovascular disease, and chronic atrial fibrillation, was admitted and had specific tube feeding orders in place. On 02/18/2025, the Registered Dietician made recommendations to change the resident's tube feeding formula and add liquid protein supplements. These recommendations were faxed to the Medical Director's office the same day. However, there was no follow-up via telephone after the facility did not receive a response from the Medical Director. The facility did not receive any correspondence regarding the recommendations until 03/05/2025, after the resident had already passed away in the hospital. Interviews confirmed that the process for follow-up was not completed as required by facility policy.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from various forms of abuse and neglect, resulting in an Immediate Jeopardy situation. A staff member, identified as a CNA, verbally abused a resident by yelling and using profanity, which caused emotional distress and fear. The resident, who was cognitively intact, reported the incident to the administrator, but the response was inadequate as the staff member was merely reassigned to a different hall without further investigation or action. Additionally, there were incidents of resident-to-resident physical abuse. One resident, who had a history of aggressive behavior, hit another resident in the face with a box of cookies and later pulled another resident's hair. These incidents were not properly addressed or reported as abuse by the facility's administration, indicating a lack of appropriate response to resident altercations and failure to ensure a safe environment for all residents. Furthermore, the facility neglected a resident by failing to adhere to the required two-person assist with a mechanical lift during transfers. A CNA transferred the resident alone, without the necessary equipment, despite the care plan clearly indicating the need for a two-person assist. This neglectful action was not isolated, as other staff members also admitted to transferring residents without assistance due to staffing issues, highlighting systemic neglect in adhering to care protocols.
Removal Plan
- S4 CNA was placed on administrative leave pending thorough investigation.
- All current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure.
- Monitoring tool initiated for S5 CNA Supervisor or designee to complete the lift protocol monitoring tool 4 times a week for 4 weeks, then twice per week for 2 weeks to ensure compliance with lift protocol and mechanical lifts for residents who require 2 person transfer.
- Monitoring tool initiated for every 15 minute and every 30 minute checks for Resident #6, Resident #15, Resident #25, and Resident #51, and shall be turned into S2 DON daily for review.
- S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
- Monitoring tool initiated for review of the nurses notes from the prior day in the weekly morning stand up meeting with IDT team. Any findings/allegations shall be reported to S1 Administrator immediately.
- All on coming staff was in-serviced on the facility's Abuse and Neglect Policy and Procedure.
- There was a mandatory all staff meeting on the facility's Abuse and Neglect Policy and Procedure which addressed the required components to include reporting protocols and 2 hour timeline in which to report alleged incidents into SIMS. Staff member who had not received in-service would be required to receive in-service prior to beginning their scheduled shift.
- S6 CNA was in serviced on the policy and procedure for patients requiring mechanical lift.
- Return demonstration for S6 CNA was required. Visual return demonstration was observed by S2 DON.
- Resident #68 was discharged home.
- Interviews were conducted with Resident #15, Resident #6, Resident #25, and Resident #51 to ensure freedom of abuse/neglect. Resident #15 shall continue to be on every 30 minute checks indefinitely. Resident #6 was placed on every 30 minute checks indefinitely. Resident #25 had every 15 minutes checks for 24 hours, then every 30 minute checks indefinitely. Resident #51 was placed on every 30 minute checks for two weeks.
- Resident #25's psychiatrist was informed of resident's behaviors. No new orders were given.
- The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.
Failure to Report Abuse Incidents in a Timely Manner
Penalty
Summary
The facility failed to report several instances of abuse involving both staff-to-resident and resident-to-resident interactions. One incident involved a CNA who verbally abused a resident by yelling and using profanity, which was reported by the resident to the administrator. Despite the resident expressing fear and discomfort, the facility did not report this incident to the State Agency as required. Another incident involved a resident with severe cognitive impairment who physically assaulted two other residents on separate occasions. The first altercation involved the resident hitting another resident in the face with a box of cookies, and the second involved the resident pulling another resident's hair. These incidents were documented in the facility's progress notes, but the facility did not report them to the State Agency, as the Director of Nursing did not perceive them as abuse. The facility's failure to report these incidents in a timely manner, as mandated by state law, resulted in an Immediate Jeopardy situation. The lack of proper reporting and investigation of these abuse allegations has the potential to affect all residents within the facility.
Removal Plan
- All current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure.
- S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
- All on coming staff was in-serviced on the facility's Abuse and Neglect Policy and Procedure.
- There was a mandatory all staff meeting on the facility's Abuse and Neglect Policy and Procedure which addressed the required components to include reporting protocols and 2 hour timeline in which to report alleged incidents into SIMS. Staff member who had not received in-service would be required to receive in-service prior to beginning their scheduled shift.
- The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal, physical, and mental abuse involving three residents. Resident #15, who is cognitively intact, reported an incident where a CNA yelled at her using derogatory language, which caused her emotional distress and fear. Despite Resident #15 reporting the incident to the Administrator, the facility did not consider it an abuse allegation and failed to conduct an investigation or monitor the CNA's behavior. Resident #51 experienced a physical altercation when another resident, Resident #25, hit her in the face with a box of cookies. Although the incident was documented, the Director of Nursing (DON) did not investigate it further, as she was not informed of the physical aspect of the altercation. This lack of investigation left the incident unaddressed, despite the potential for harm. Resident #6, who has severe cognitive impairment, was involved in an incident where Resident #25 pulled her hair. The DON did not perceive this as abuse and did not investigate further, despite a witness reporting the altercation. The facility's failure to recognize and investigate these incidents as abuse resulted in an Immediate Jeopardy situation, as the safety and well-being of the residents were compromised.
Removal Plan
- All current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure.
- S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
- Monitoring tool initiated for review of the nurses notes from the prior day in the weekly morning stand up meeting with IDT team. Any findings/allegations shall be reported to S1 Administrator immediately.
- There was a mandatory all staff meeting to discuss Abuse and Neglect Policy and Procedure, Lifting protocols, and the facility's Use of Mechanical Lift. In-service included monitoring for a reporting resident to resident abuse, staff to resident abuse, and neglect. In addition, reporting and investigation requirements of all alleged incidents of abuse and neglect. The facility shall thoroughly investigate any and all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse and neglect.
- The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.
Failure to Provide Water with Meals
Penalty
Summary
The facility failed to provide drinks consistent with resident preferences and needs, specifically failing to offer water to 10 residents during lunchtime in Hall X dining room. Observations on two consecutive days revealed that staff served lunch trays with only juice and milk, without offering or providing water. Interviews with the S5 CNA Supervisor confirmed that the kitchen did not include water on the meal trays, and water was only provided if specifically requested by a resident.
Deficiency in Abuse and Neglect Reporting and Response
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in multiple instances of abuse and neglect affecting five residents. One resident was subjected to verbal abuse by a CNA, who yelled derogatory remarks, causing emotional distress and fear. Another resident experienced physical abuse from a fellow resident, who hit them with a box of cookies, leading to anger and distress. Additionally, a resident was neglected when a CNA failed to follow the required two-person assist protocol during a transfer, risking physical harm. The facility did not have an effective system in place to ensure that all alleged violations involving abuse and neglect were reported immediately. This failure was evident in the lack of timely reporting of incidents involving verbal and physical abuse, as well as neglect. The facility's administration did not recognize certain incidents as abuse, leading to a lack of investigation and monitoring of the involved staff and residents. This oversight contributed to the continuation of abusive and neglectful situations within the facility. Interviews with the facility's administration revealed a lack of awareness and understanding of the incidents as abuse or neglect. The Director of Nursing and Administrator did not consider certain incidents as reportable, resulting in a failure to investigate and report them to the State Agency. This deficiency in recognizing and addressing abuse and neglect compromised the safety and well-being of the residents, highlighting significant gaps in the facility's policies and procedures for handling such incidents.
Removal Plan
- In-service was completed with all current staff on shift for abuse and neglect policy and procedure, lifting protocol, and what constitutes abuse and neglect.
- S4 CNA was placed on administrative leave pending thorough investigation.
- S6 CNA was in services on proper lifting techniques with proper return demonstration completed.
- S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
- Administrative oversight was provided to S1 Administrator and S2 DON by the regional administrator. The regional administrator shall thoroughly investigate all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Regional administrator will monitor S1 Administrator weekly by direct observation and onsite oversight weekly for 30 days.
- There was a mandatory all staff meeting to discuss Abuse and Neglect Policy and procedure, reportable incidents, lifting protocols, and use of lifters. In-service also included monitoring for and reporting resident to resident abuse, staff to resident abuse, and neglect. The facility shall thoroughly investigate any and all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Any staff member not in serviced will be in serviced prior to the beginning of their shift.
- A monitoring tool was initiated for nurse's notes to be reviewed daily for any alleged cases of abuse and neglect to be investigated as necessary. All alleged cases will be brought to S2 DON and S1 Administrator's attention and investigation and reporting are to be done immediately.
- The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.
Inconsistent Documentation of Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was properly documented in their medical record. Specifically, there was inconsistency in the documentation of the resident's code status. The resident, who had a history of cerebrovascular disease, dysphagia following cerebral infarction, generalized anxiety disorder, bipolar disorder, and chronic systolic heart failure, was listed as a Full Code in the electronic record dashboard/orders, while the physician's orders and care plan indicated a DNR (Do Not Resuscitate) status. Interviews with facility staff revealed that the staff relied on the electronic record dashboard/orders to determine a resident's advance directive during a code. The Director of Nursing confirmed the inconsistency in the resident's electronic record and care plan regarding the advance directive and acknowledged that the records should have been updated to reflect the correct DNR status, but they were not.
Failure to Complete PASARR Level II Screening for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a mental disorder had an accurately completed PASARR Level II screening. The deficiency was identified for a resident who was admitted with a Level I PASARR screening, which indicated no need for a Level II screening due to the absence of a mental illness diagnosis at the time of admission. However, after admission, the resident was diagnosed with Bipolar Disorder, which should have triggered a Level II screening according to the facility's PASARR policy. The deficiency was confirmed through a review of the resident's medical records and an interview with the Director of Nursing (DON). The records showed that the resident was diagnosed with Bipolar Disorder after admission, and a psychiatric evaluation indicated persistent symptoms of depression and delusions. Despite these developments, the required Level II screening was not completed, as confirmed by the DON during the interview.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for three residents, leading to deficiencies in their care. Resident #34, who has a history of falls and requires a fall mat as per physician's orders, was observed multiple times without the fall mat in place. Despite the care plan and physician's orders specifying the need for a fall mat, it was not present at the bedside, as confirmed by both the LPN and the DON. Resident #36, who also has a history of falls and requires a fall mat, was observed with the fall mat propped against the wall instead of being placed on the floor beside the bed. This improper placement of the fall mat was confirmed by the DON, who acknowledged that the mat should have been on the floor to prevent falls. Resident #37, who requires two-person assistance for bed mobility and toileting, experienced a fall when a CNA attempted to provide care alone. The care plan clearly indicated the need for two-person assistance, but this was not followed, resulting in the resident rolling out of bed during incontinent care. The DON confirmed that the CNA did not adhere to the care plan, leading to the incident.
Failure in Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a Stage 3 pressure ulcer on the sacral region. The resident, who was admitted with multiple diagnoses including cerebrovascular disease, dysphagia, generalized anxiety disorder, bipolar disorder, and chronic systolic heart failure, had specific physician orders for wound care. These orders included cleaning the ulcer with a wound cleanser, applying Santyl, and using a collagen dressing covered with a silicone bordered foam dressing, to be changed daily or as needed. However, during an observation of wound care, the treatment nurse placed clean gloves on an unclean bedside table, which was on top of the resident's belongings, before using them for wound care. This action contaminated the gloves, which were then used to clean the wound. Additionally, the treatment nurse failed to follow proper infection control procedures by not removing soiled gloves and sanitizing hands before obtaining new supplies from the clean field and continuing with the wound care. This lapse in protocol was confirmed during an interview with the treatment nurse, who acknowledged the findings. The failure to adhere to professional standards of practice in wound care compromised the resident's treatment and potentially increased the risk of infection.
Failure to Administer Enteral Flush as Ordered
Penalty
Summary
The facility failed to administer a resident's enteral flush according to the physician's orders. The resident, who was admitted with conditions including cerebrovascular disease, dysphagia following cerebral infarction, generalized anxiety disorder, bipolar disorder, and chronic systolic heart failure, had a physician's order for Glucerna 1.5 cal at 60cc/hour with 35cc/hour water flushes per pump. However, observations on two consecutive days revealed that the resident's water flush was set at 30cc/hour instead of the prescribed 35cc/hour. An interview with the Assistant Director of Nursing confirmed that the water flush was incorrectly set, deviating from the physician's orders.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident by not administering oxygen as ordered by the physician. The resident, who was admitted with diagnoses including cerebrovascular disease, shortness of breath, and severe cognitive impairment, was dependent on staff for activities of daily living and required continuous oxygen therapy. The physician's order specified oxygen at 2 liters per minute via nasal cannula, but observations on two consecutive days revealed the oxygen was set at 3 liters per minute. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the oxygen settings were not in accordance with the physician's order. The LPN acknowledged that the oxygen concentrator was set incorrectly and should have been at 2 liters per minute. The Director of Nursing also confirmed that a physician's order is required to adjust oxygen settings, indicating a failure to adhere to the prescribed care plan for the resident.
Failure to Maintain Accurate Narcotic Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of drugs to meet the needs of each resident. During an observation, it was noted that the narcotic log for a resident's Gabapentin 300mg capsules showed 18 capsules documented, but the blister pack contained only 17 capsules. Similarly, the narcotic log for the same resident's Morphine 30mg tablets showed 2 tablets documented, while the blister pack contained only 1 tablet. The LPN responsible for administering these medications admitted to not signing out the medications on the narcotic record log sheet after administration. Another resident's narcotic record log for Gabapentin 300mg capsules showed 44 capsules documented, but the blister pack contained 43 capsules. The LPN confirmed that she failed to update the narcotic record log sheet with the correct amount remaining in the medication packs after administering the medications. The Director of Nursing confirmed that all controlled medications should be signed off on the narcotic record log sheet immediately after administration by the nurse.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodation of needs, specifically regarding the placement of a call bell. The deficiency was identified for a resident who had a history of cerebral infarction, CVA, seizure disorder, and hypertension, and was cognitively impaired with a BIMS score of 8. The resident was dependent on staff for activities of daily living, including oral hygiene, showering, bathing, and dressing. Despite the facility's policy requiring call bells to be within reach, observations on multiple occasions revealed the call bell was draped over a plug-in receptacle box on the wall behind the resident, making it inaccessible. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the resident was capable of using the call bell to request assistance. However, the call bell was repeatedly found out of reach during observations. The LPN confirmed the call bell's inaccessibility and subsequently placed it within reach, allowing the resident to activate it. The facility's failure to ensure the call bell was consistently within reach of the resident constituted a deficiency in accommodating the resident's needs.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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